TO FILE A CLAIM WITH THE TOWNSHIP OF NEPTUNE 1. Police...
Transcript of TO FILE A CLAIM WITH THE TOWNSHIP OF NEPTUNE 1. Police...
Page | 1 Notice of Tort Claim 92L10
TO FILE A CLAIM WITH THE TOWNSHIP OF NEPTUNE
In order to efficiently process your claim, the following documents need to be
submitted to the office of Human Resources:
1. Police Report of accident/incident
2. Front page of the claimants Insurance Policy known as the
“Deceleration Sheet”
This is required by our insurance carrier in order to comply with State
Statue, Title 59:9-2e.
This does not mean that the individual’s insurance company is being notified
of the accident/incident.
3. Estimate for repairs/damages
When these three items are submitted to the Human Resources Dept., a report will
be filled out by our office and forwarded with the claim to the Township’s insurance
carrier within one week. Our insurance carrier will then get in touch with the person
filing the claim within seven to ten (7-10) business days of receipt of the claim. Of
course, we will do whatever we can to shorten this time frame in order to make the
circumstances easier for you.
If you have any questions about the process or problems, please feel free to contact
Stephanie Oppegaard in the Office of Human Resources at
732-988-5200 Ext. 230.
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TOWNSHIP OF NEPTUNE Municipal Complex
25 Neptune Boulevard
Neptune, New Jersey 07754-1125
NOTICE OF TORT CLAIM
CLAIMANT INFORMATION
Name _____________________________ Telephone ________________________
Address ___________________________ Date of Birth _______________________
___________________________________ SSN ______________________________
ATTORNEY INFORMATION (if applicable)
Name _____________________________ Telephone ________________________
Address ___________________________ Date of Birth _______________________
___________________________________ SSN ______________________________
Send Notices to : _________ Claimant __________ Attorney
GENERAL INSTRUCTIONS: Pursuant to the provisions of the New Jersey Tort Claims Act, this
Notice of Tort Claim form has been adopted as the official form for the filing of claims against the
Township of Neptune. The questions are to be answered to the extent of all information available
to the Claimant or to his or her attorneys, agents, servants, and employees, under oath. The fully
completed Claim Form and the documents requested shall be returned to:
Stephanie Oppegaard
Township of Neptune
25 Neptune Boulevard
P. 0. Box 1125
Neptune, New Jersey 07754-1125
NOTE CAREFULLY: Your claim will not be considered filed as required by the New Jersey Tort
Claims Act until this completed form has been filed with the Township of Neptune. Failure to
provide the information requested, including such responses as "To be Provided'' or "Under
Investigation" will result in the claim being treated as not being properly filed. Timely Notices of
claim must be filed within 90 days after the incident giving rise to the claim.
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This form is designed as a general form for use with respect to all claims. Some of the
questions may not be applicable to your particular claim. For example, if your claim does not
arise out of an automobile accident, questions regarding road conditions might not be applicable.
In that event, please indicate "Not Applicable."
If you are unable to answer any questions because of a lack of information available to
you, specify the reason the information is not available to you. If a question asks that you identify
a document, it will be sufficient to furnish true and legible copies. Where a question asks that
you "identify all persons," provide the name, address and telephone number of the person.
If you need more space to provide a full answer, attach supplementary pages, identifying
the continuation of the answer with the number of the applicable question.
DEFINITIONS:
• "Claimant" shall refer to the person or persons on whose behalf the Notice of Claim has
been filed with the Township of Neptune.
• "Document" shall refer to any written, photographic or electronic representation, and
any copy thereof, including, but not limited to, computer tapes and/or disks, videotapes and
other material relating to the subject matter of the claim.
• "Person" shall include in its meaning a partnership, joint venture, corporation,
association, trust or any other kind of entity, as well as a natural person.
• "Public Entity" shall refer to the Township of Neptune along with any agent, official or
employee of the Township of Neptune against whom a claim is asserted by the Claimant.
NOTE that the questions are divided into sections relating to the claimant, the claim, property
damage, personal injury and the basis for the claim against the public entity or public employee.
If the claim involves only property damage, then the portion on personal injuries need not be
answered. Just enter as the answer to Question 12 "No personal injuries claimed." If the claim
involves no property damage then the portion on property damage need not be answer. Just
enter as the answer to Question 11 "No property damage claimed."
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INFORMATION ON THE CLAIMAINT
1. Provide the following information with respect to the Claimant:
a. Any other name by which the Claimant has been known.
b. Address at the time of the incident giving rise to the claim.
c. Marital Status (at the time of the incident and current)
d. Identify each person residing with the claimant and the relation, it any, of the person
to the Claimant.
2. Provide all addresses of the Claimant for the last 10 years, the dates of the residence, the
persons residing at the addresses at the same time as the Claimant resided at the address and
the relation, if any of the person to the Claimant.
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INFORMATION ON ALL CLAIMS
3. Provide the exact date, time and place of the incident forming the basis of the claim and the
weather conditions prevailing at the time.
4. Provide the Claimant's complete version of the events that form the basis of the claim.
5. List any and all individuals who were witnesses to or who have knowledge of the facts of the
incident which gave rise to the claim. Provide the full and name and address of each individual.
6. Identify all public entities or public employees (by name and position) alleged to have caused
the injury or property damage and specify as to each public entity or employee the exact nature
of the act or omission alleged to have caused the injury or property damage.
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7. If you claim that the injury or property damage was caused by a dangerous condition or property
under the control of the public entity, specify the nature of the alleged dangerous condition and
the manner in which you claim the condition caused the injury.
8. If you allege a dangerous condition of public property, state the specific basis on which you
claim that the public entity was responsible for the condition and the specific basis and date on
which you claim that the public entity was given notice of the alleged dangerous condition.
Statements such as "should have known" and "common knowledge" are insufficient.
9. If you or any other party or witness consumed any alcohol beverages, drugs or medications
within twelve (12) hours before the incident forming the basis of the Claim, identify the person
consuming the same and for each person (a) what was consumed (b) the quantity thereof
(c) where consumed (d) the names and addresses of all persons present.
10. If you have received any money or thing of value for your injuries or damages from any
person, firm or corporation, state the amounts received, the dates, names and addresses of the
payers. Specifically list any policies of insurance, including policy number and claim number,
from which benefits have been paid to you or to any person on your behalf, including doctors,
hospitals or any person repairing damage to property.
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11. If any photographs, sketches, charts or maps were made with respect to anything which is the
subject matter of the claim, state the date thereof, the names and addresses of the persons
making the same and of the persons who have present possession thereof. Attach copies of any
photographs, sketches, charts or maps.
12. If you or any of the parties to this action or any of the witnesses made any statements or
admissions, set forth what was said; by whom said; date and place where said; and in whose
presences, giving names and addresses of any persons having knowledge thereof.
13. State the total amount of your claim and the basis on which you calculate the amount claimed.
14. Provide copies of all documents, memoranda, correspondence, reports (including Police
Reports) etc., which discuss, mention or pertain to the subject matter of this claim.
15. Provide the names and addresses of all persons or entities against whom claims have been made
for injuries or damages arising out of the incident forming the basis of this claim and gives the
basis for the claim against each.
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16. If your claim is for property damage, attach a description of the property damage and an
estimate of the costs of repair. If your claim does not involve any claim for property damage,
enter "None."
________ If your claim is for property damage only initial here and proceed directly to page
12 and sign the Certification.
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PERSONAL INJURY CLAIMS
17. Was any complaint made to the public entity or to any official or employee of the public
entity. State the time and place of the complaint and the person or persons to whom the
complaint was made.
18. Describe in detail the nature, extent and duration of any and all injuries.
19. Describe in detail any injury or condition claimed to be permanent.
20. If confined to any hospitals, state name and address or each and the dates of admission and
discharge. Include all hospital admissions prior to and subsequent to the alleged injury and
give the reason for each admission.
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21. If x-rays were taken, state (a) the address of the place where each was taken (b) the name and
address of the person who took them (c) the date when each was taken (d) what each
disclosed (e) where and in whose possession they now are. Include all x-rays, whether prior to
or subsequent to the alleged injury forming the basis of the claim.
22. If treated by doctors, including psychiatrists or psychologists, state
(a) the name and present address of each doctor
(b) the dates and places where treatments were received
(c) the nature of the treatment
(d) the date of last treatment or, if treatments are continuing, the schedule of continuing
treatments. Provide true copies of all written reports rendered to you or about you by any doctors
whom you propose to have testify on your behalf.
23. If you have any physical impairment which you allege is caused by the injury forming the basis
of your claim and which is affecting your ordinary movements, hearing or sight, state in detail
the nature and extent of the impairment and what corrective appliances, support or device you
use to overcome or alleviate the impairment.
24. If you claim that a previous injury has been aggravated or exacerbated, describe the injury and
give the name and present address of each doctor who treated you for the condition, the period
during which treatment was received and the cause of the previous injury. Specifically list any
impairment, including use of eyeglasses, hearing aid or similar device, which existed at the time
of the injury forming the basis of the claim.
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25. If any treatments, operation or other form of surgery in the future has been recommended to
alleviate any injury or condition resulting from the incident which forms the basis of the claim,
state in detail
(a) the nature and extent of the treatment, operation or surgery
(b) the purpose thereof and the results anticipated or expected
(c) the name and address of the doctor who recommended the treatments, operation or surgery
(d) the name and address of the doctor who will administer or perform the same
(e) the estimated medical expenses to be incurred
(f) the estimated length of time of treatments, operation or surgery, period of hospitalization
and period of convalescence
(g) all other losses or expenditures anticipated as a result of the treatments, operation or surgery
(h) whether it is your intention to undergo the treatments, operation or surgery and the
approximate date.
26. Itemize any and all expenses incurred for hospitals, doctors, nurses, x-rays, medicines, care
appliances and indicate which expenses were paid by any insurance coverage.
27. If employed at the time of the alleged injury forming the basis of the claim state (a) the name
and address of the employer (b) position held and the nature of the work performed, average
weekly wages for the year prior to the injury ( d) period of time lost from employment, giving
dates ( e) amount of wages lost, if any. List any sources of income continuation or replacement,
including, but not limited to, workers' compensation, disability income, social security and
income continuation insurance.
28. If other loss of income, profit or earnings is claimed, state (a) total amount of the loss
(b) Give a completed detailed computation of the loss (c) the nature and dates of loss
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29. If you are claiming lost wages state (a) the date that the employment began (b) the name and
address of the employer (c) the position held and the nature of the work performed (d) the
average weekly wages. Attach copies of pay stubs or other complete payroll records for all
wages received during the past year.
DOCUMENT REQUEST: Produce all documents identified in your answers to the
above questions.
CERTIFICATION
I hereby certify that the information provided is the truth and is the full complete
response to the questions, to the best of my knowledge.
__________________________________
Signature of Claimant
Dated: _________________________
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AUTHORIZATION FOR RELEASE OF
MEDICAL AND HOSPITAL RECORDS
TO: ___________________________________ DATE: _____________________
___________________________________
___________________________________
RE: ___________________________________ _________________________________ (Patient’s Name) (Social Security Number)
___________________________________ (address)
___________________________________
___________________________________
___________________________________ (Claim Number)
You are hereby authorized and requested to disclose, make available and furnish to:
Stephanie Oppegaard
Township of Neptune
25 Neptune Blvd
Neptune, NJ 07753
All information, records, ex-rays, reports or copies thereof relating to my examination, consultation,
confinement or treatment and to permit her/him to inspect and make copies or abstracts thereof.
Approximate date of admission to hospital, first examination, treatment or consultation:
_____________________________________
A photocopy of this release form, bearing a photocopy of my signature, shall constitute your
authorization for the release of the information in accordance with the request made to you.
____________________________________
Signature
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AUTHORIZATION FOR RELEASE OF EMPLOYMENT RECORDS
TO: ____________________________________ DATE: ____________________
____________________________________
____________________________________
RE: ___________________________________ (Employee’s Name)
___________________________________ (address)
___________________________________
___________________________________
___________________________________ (Claim Number)
You are hereby authorized and requested to disclose, make available and furnish to:
Stephanie Oppegaard
Township of Neptune
25 Neptune Blvd
Neptune, NJ 07753
All information relating to my employment, including, but not limited to, my job title, assigned
duties, compensation, benefits, attendance, and sick leave and to permit him or her to inspect
and make copies or abstracts thereof.
A photocopy of this release form, bearing a photocopy of my signature, shall constitute your
authorization for the release of the information in accordance with the request made to you.
____________________________________
Signature